Niles Care Center, LLC
911 S 3rd St, Niles, MI 49120 · Berrien County · 100 certified beds · avg 53 residents/day · certified since Jul 1, 1978
Part of chain: AVON HEALTHCARE (9 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 20, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 21, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 20, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 21, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 10, 2025 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 4, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 4, 2023 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (41)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 17, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 17, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jan 23, 2026 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jan 23, 2026 | F · Potential for harm, facility-wide | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Jan 23, 2026 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Jan 23, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Dec 10, 2025 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Dec 10, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Aug 20, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 20, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 5, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 5, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 5, 2024 | F · Potential for harm, facility-wide | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Dec 5, 2024 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 24, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 24, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 24, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 25, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Oct 25, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 25, 2023 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Oct 25, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 25, 2023 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Oct 25, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 4, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 4, 2023 | ▲ G · Actual harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 2 | G ▲ |
| 2024 | 18 | 0 | F |
| 2025 | 4 | 3 | J ▲ |
| 2026 | 11 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $158,405, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Aug 20, 2025 | Fine | $75,595 |
| Dec 5, 2024 | Payment Denial | 51 days from Jan 11, 2025 |
| Oct 4, 2023 | Fine | $82,810 |
| Oct 4, 2023 | Payment Denial | 28 days from Oct 26, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Michigan avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.01 | 4.32 | 3.95 | bottom 46% in Michigan; top 39% in the U.S. |
| Registered Nurse hours | 0.62 | 0.84 | 0.69 | bottom 31% in Michigan; top 45% in the U.S. |
| Weekend total nurse staffing | 3.48 | 3.79 | 3.50 | bottom 41% in Michigan; top 43% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.25 | 0.49 | 0.48 | bottom 17% in Michigan; bottom 21% in the U.S. |
| Total nursing staff turnover (%) | 67.8 | 44.1 | 45.8 | bottom 3% in Michigan; bottom 8% in the U.S. |
| RN turnover (%) | 90.0 | 39.2 | 42.9 | bottom 1% in Michigan; bottom 2% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.45, RN 0.54, weekend 2.99. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company · changed ownership in the last 12 months
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gottlieb, Moshe | Individual | 5% or Greater Direct Ownership Interest | 48% | 09/01/2025 |
| Cain, Cynthia | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2025 |
| Freund, Eliyahu | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2025 |
| Freund, Eliyahu | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2025 |
| Gottlieb, Moshe | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2025 |
| Gottlieb, Moshe | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2025 |
| Ibekie, Oranu | Individual | ADP of the SNF | NOT APPLICABLE | 11/03/2025 |
| Niles Avon Management | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2025 |
| Niles Avon Management | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2025 |
| Niles Care Center Propco | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2025 |
| Sears, Monica | Individual | ADP of the SNF | NOT APPLICABLE | 11/03/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "How do you track each resident's food allergies and preferences, and what happens if they don't like what's served?"
- "How does your quality committee work, and can you share an example of a problem it identified and fixed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Orchards at Niles | 1.6 mi | Niles, MI | ★☆☆☆☆ | 1/5 | |
| West Woods of Niles | 4.0 mi | Niles, MI | ★☆☆☆☆ | 1/5 | |
| Healthwin Health & Rehabilitation | 6.1 mi | South Bend, IN | ★★☆☆☆ | 2/5 | |
| Majestic Care of South Bend | 6.4 mi | South Bend, IN | ★☆☆☆☆ | 1/5 | |
| Wellbrooke of South Bend | 7.5 mi | South Bend, IN | ★★★★☆ | 3/5 | |
| Holy Cross Rehabilitation and Wellness | 7.7 mi | South Bend, IN | ★★☆☆☆ | 2/5 | |
| Belltower Health & Rehabilitation Center | 8.5 mi | Granger, IN | ★★★★☆ | 4/5 | |
| Holy Cross Village at Notre Dame INC | 8.6 mi | Notre Dame, IN | ★★★☆☆ | 3/5 | |
| Creekside Village | 8.7 mi | Mishawaka, IN | ★★★★☆ | 3/5 | |
| Brickyard Healthcare - Fountainview Care Center | 8.9 mi | Mishawaka, IN | ★★☆☆☆ | 2/5 | |
| Milton Home, the | 9.4 mi | South Bend, IN | ★★★★★ | 4/5 | |
| Cardinal Nursing and Rehabilitation Center | 9.7 mi | South Bend, IN | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 235361.